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The problem with harm reduction is that people who ought to understand it, clearly don’t.

17, Feb, 2017

By Tom Pruen

Today saw the publication of a very interesting (albeit not in the way the authors intended) article in the Journal of Public Health Policy, “Harm reduction and e-cigarettes: Distorting the approach”.

Sadly, the main point proven by the article is that the authors have completely failed to understand harm reduction.

They state that:

“Harm reduction is not seen as a process for allowing open access to drugs. Rather it is a method of making available, in a controlled and regulated way, the drug that those people for whom other options have not been successful seek in a form that is safer — methadone for some who are addicted to heroin, for example.”

This is, quite frankly, an awful analogy.

1. Access to heroin is illegal while the most dangerous form of nicotine, smoked tobacco, is widely and legally available

2. Methadone is not heroin. It is a substitute, synthetic, opioid.

Most of the harms that result from the use of heroin are a result of its legal status - high cost, criminalisation of users, debateable and variable purity, needle sharing and unsanitary injection.

Most of the harms that results from the use of nicotine result from its delivery method – setting treated leaves on fire and inhaling the resulting smoke.

This is comparing two circumstances that are so wildly different I cannot see how it can be justified (unless all non-medicinal nicotine was outlawed, including tobacco – a regulatory move that would not be widely supported – and treatment offered to addicts). A better analogy would be that since injecting is dangerous, no needles should be supplied except for strictly supervised treatments. However, history tells us that this makes injecting more dangerous, not less.

Again, this misses a fundamental harm reduction point. One of the things that sets e-cigs apart from other nicotine sources (with the possible exception of snus, where it is not legally prohibited), is that it actually appeal to existing smokers. If offering a safer alternative to the nicotine market, that people who are currently using the most dangerous alternative find appealing, isn’t demand reduction, what is it?

What better way can there be of making smoking history than by reducing the number of people who want to buy cigarettes?

Better still, if this kind of demand reduction can be achieved, the supply of smoked tobacco offers little economic incentive and will fade away all by itself, instead of being a multi-billion dollar business.

However, instead of welcoming the idea that people who use nicotine will switch to safer sources, reducing the demand for tobacco, the authors suggest that:

“A comprehensive tobacco control strategy that includes harm minimisation would need to incorporate the first element: demand reduction. It would, we believe, employ the same bans on promotion that apply to conventional cigarettes; would restrict the use of electronic cigarettes in public places; would ensure government- determined warning information; and would apply strict restrictions on any forms of marketing that indirectly promoted brands of conventional cigarettes.”

In other words, rather than offering reduced harm nicotine containing products for smokers, we should treat all nicotine the same, regardless of the potential for harm that its delivery method offers (oddly the last point on marketing is one that consumers and the vast majority of the industry would agree with – no-one with a genuine interest in harm reduction would want to market cigarettes).

A good analogy for this would that since refined sugar in soft drinks has been linked to increased morbidity, we should ban fruit juice.

We then (finally) move on to actual harm reduction, although seen through a rather distorting lens.

The authors do acknowledge that:

“The evidence so far indicates e-cigarettes are less harmful than conventional cigarettes.”

But…

“Harm minimisation policies have a goal to protect users and, as with clean needles for injection drug users, require that the products are as safe as they possibly can be”

This again, rather misses the point. Harm reduction for drug users in this context supplies them with a clean delivery method, to reduce their risk, but they continue to be exposed to the risks of the actual drugs themselves. This is actually the most relevant comparison made so far, except…

“For e-cigarettes, such an approach might, for example, place much more stringent restrictions on those products and flavours that have not been tested for long-term safety when inhaled. Manufacturing of the products would also have to be strictly regulated to ensure consistency and safety.”

The best analogy for this would be that never mind supplying clean needles for drug users, we should supply them with pharmaceutical heroin. This would work, but is not a widely utilised method.

In summary then:

“In summary, although those promoting the use of electronic cigarettes are seeking to link their use explicitly to the concept of harm reduction, this comparison distorts a comprehensive harm minimisation policy”

The problem that is clearly expressed is that

1. The authors don’t understand harm reduction

2. They have also confused harm reduction, and harm minimisation

The irony of this, in an article that claims that other people have misunderstood harm reduction, is staggering.